What to Expect if You Appeal the Audit Results

By Laura Loeb, Esq.Hogan & Hartson LLPOutside Counsel to IDSA

If you appeal the audit results, you will be provided with a fair hearing. A lawyer is not absolutely necessary for the hearing because it is rather informal. Nevertheless, it is probably a good idea to have one. The hearing may take place in person or over the telephone. After your request for a fair hearing, it may not be scheduled for six months to a year.

In the meantime, you will want to submit supplemental information. As stated above, the focus of audits for infectious diseases physicians typically is E&M codes. The payer has compared your documentation to the E&M documentation guidelines developed by AMA and HCFA. These guidelines went into effect Aug. 1, 1995. The 1995 guidelines relate to a comprehensive, multi-system examination. In 1997, AMA and HCFA adopted guidelines for single system examinations. Usually, the 1995 guidelines are a little more relevant to the clinical work of the infectious diseases physician. However, neither set of guidelines is particularly applicable to the type of examination or consultation provided by an infectious diseases physician.

The guidelines were never intended to be the absolute standard that they have become to auditors. They are guidelines, not requirements. Nevertheless, they are used as requirements. The payer itself will not be terribly sympathetic to the argument that a high level E&M code is perfectly justifiable if one looks at the overall record and clinical condition of the patient. However, a fair hearing officer is often persuaded by such evidence.

Therefore, I recommend that you prepare a detailed description of the clinical condition of each patient under review that extensively elaborates on what you as the physician must have done and the decision-making process that must have transpired. You should focus on all tests that must have been reviewed, the patient's vital signs, what you had to rule out, etc.

During the hearing itself, you should recount each patient's record in excruciating detail, leaving nothing out. As the physician, you chose this level E&M code; you will need to defend your choice. More often than not, you will be able to do this.